Dr Shabnam Berry-Khan, clinical psychologist, case manager and director of PsychWorks Associates, discusses trauma in brain injury clients, how to recognise its impact, and why the client and their entire network – including the treating professionals – must be supported through its effects
Did you know it is estimated that one in two adults will experience some degree of trauma in their lifetime?
Did you also know that 10 per cent of the general adult population experience Post-Traumatic Stress Disorder (PTSD)?
Trauma can be defined as the impact of a particularly jarring event, whether it’s life-threatening or harmful physically or emotionally, which has lasting effects on psychological health. It can result from anything that causes fear, helplessness and horror.
The bigger the impact, the more likely it is to result in PTSD or complicated presentations. And the more likely it is to affect others too, known as vicarious trauma.
Trauma is not without its complexities and the relationship to traumatic brain injury (TBI) is an interesting one. This article aims to unpick trauma and its symptoms as well as understand how it relates to TBI, and what professionals working with TBI clients need to think about.
So, what causes trauma?
Trauma can arise from many different events. It could be a single incident, such as a life-changing injury or bereavement. Or it could stem from repeated exposure to negative events, such as from domestic violence or childhood abuse.
It can be intergenerational, with trauma passing from parents to children, as we often see in refugees and migrants. Trauma can also be caused by systemic abuse, such as institutional racism.
Finally, trauma can be experienced vicariously, through working or living with individuals whose lived stories are in themselves traumatic. Yes, that’s right: it is a recognised occupational hazard among helping professionals and family carers.
- Psychological symptoms of trauma include anxiety, sadness, confusion, anger, difficulties regulating mood; denial and shock, controlling behaviours, being withdrawn, low self-esteem; mistrust of others, difficulties with relationships, self-destructive behaviours, and feelings of shame. Physical symptoms include sleep issues, muscle tension, and low energy or fatigue.
On the other hand, Post-Traumatic Stress Disorder (PTSD) encompasses very specific symptoms. They are:
- repeated and unwanted re-experience of the traumatic event
- avoidance of anything – people, circumstances, experiences – that could trigger recollections of that event
- hyperarousal or hypervigilance
- emotional numbing.
And how is trauma understood?
Psychologists use their assessment and formulation skills to identify, unpick and piece back together exactly what the predominant factors are that result in distress. An understanding of client backgrounds, early years experiences, school and work, physical health, family circumstances, lifestyles, and relationships is developed and explored. Psychological models and theories are applied to inform the jigsaw-piecing work.
The ‘biopsychosocial’ model of mental health enables a helpful understanding of trauma . This model proposes an interplay between the biological, psychological and social-environmental factors. All three domains influence how we develop generally, respond to the world around us and specifically how we respond to various experiences, including traumatic events.
Since trauma symptoms tend to require support, it is important to consider how the person connects with others. Using information about attachment styles will help to inform how a relationship might develop, and how that relationship might respond to challenges.
Similarly, how family dynamics play out in stressful situations, such as occur following a traumatic event, can become a protective or risk factor for the client. Professional relationships are likely to map onto styles developed in childhood. This may make certain discussions and topics difficult.
Moreover, hidden and past traumas become relevant here towards building a picture of the client. Racial or intergenerational traumas, childhood abuse and similar can result in the body and brain storing memories of trauma. Thus when a new trauma is experienced, it becomes an accumulative emotion of unprocessed past and current distress.
Seeking a full and comprehensive assessment of a client becomes incredibly relevant in trauma work.
How is trauma linked to TBI?
Neurologically speaking, trauma triggers a threat response by activating the amygdala (the part of the brain that acts like a ‘security guard’), which has the function to render less active other functions – such as the hippocampus, the ‘filing system’ centre, and the cortex, the ‘manager’ of the brain).
Processing what has happened adequately becomes impaired and pieces of information intrude into the everyday, impacting general functioning and mood. If threat is latterly perceived, the guarding amygdala triggers the threat system (thus wiping out hippocampus’ filing ability and the cortex’s management skills) again, meaning there is a similar response the brain continues not to function.
There is a significant overlap in those experiencing PTSD who are living with neurological or serious injury. PTSD is a psychological phenomenon, but it has physical links through stress and neurological changes. TBI is a neurological injury to the brain causing a range of impairments physically and cognitively, such as with thinking and learning, vision, hearing, smell, taste, social skills, behaviours, and communication. The effects of both PTSD and TBI are varied and individual-specific.
PTSD and TBI will both impact changes in cognition such as memory and concentration, depression, anxiety, insomnia, and fatigue are common with both diagnoses, where mind-body duality results in feeding and reinforcing the other’s effects.
Sadly, statistics show that people who experience TBI and PTSD have poorer outcomes. They are significantly more likely to disengage from professionals, more likely to develop other mental and physical problems, are at greater risk of exploitation or receiving poor treatment or care, and more likely to experience social breakdown for example family and professional networks.
People from BAME communities are also at greater risk of experiencing a traumatic event, and are significantly less likely to have received treatment. Those living with economic hardship are also much more susceptible to the amplification of their trauma.
Delivering trauma-informed care
When working with PTSD and/or TBI, we know that presentations:
- are mind- and body-based
- require a holistic understanding of the factors that make up the client’s distress
- may also be exacerbated by past and hidden traumas
- affect the family and professional systems
- put the client at risk.
There is a lot to consider for any professional when working with trauma clients.
Let’s consider a thought experiment: think of an event that was fearful, horrific and left you feeling powerless… think about the emotions you felt. Now imagine feeling them daily… how would you wish to be treated?
When I have spoken to colleagues about their requirements following the thought experiment, the top ten responses were fairly ‘human’:
- To have someone hold in mind their distress at all times during a meeting
- To recognise that the distress will have many facets of which only one is being dealt with in any one professional meeting. For example, while a legal meeting is taking place, a marriage might be breaking down or difficulties with care teams might be preoccupying.
- The brain does not always work as well after a trauma and that there are times when it works better and sometimes when it works less well; it might improve overall, it might not; equally, it might fluctuate. It’s complex.
- To be treated with compassion and kindness
- To be spoken to calmly and at their pace, not the professional’s pace
- To use sensitive language with explanations so anxiety is deescalated
- To not have last-minute or sudden changes, i.e. consistency
- To seek whether any support is needed
- To appreciate that any challenges in the relationship might be due to emotional dysregulation and not because of contempt
- That it might hard to articulate and explain some pain – physical or emotional – and that this does not mean any malingering is taking place.
The truth is to maintain a sustainable relationship with a client, it requires time, an openness to what trauma can indeed present like, and an approach that fosters psychological safety.
Vicarious trauma is an occupational hazard – burnout is a real possibility
It is hard to hear and hold all the traumatic stories like those I and my colleagues experience in the serious and catastrophic personal injury world. The stress of knowing what happened to clients, the devastation they have experienced and the impact on their families, the legal processes that ensues, the multi-systemic considerations from family needs to professional teams, the grief and loss experienced can take its toll. And the pressure of choosing a role which is meant to make all of this better is a lot for anyone.
And of course we, too, are human: we have our own traumas and histories, stories of sadnesses and unwanted experiences. The weight of our own needs is often enough, but then we are exposed to so much of others’ despair. The risk and challenge that can bring that the reality is in itself something to be mindful of.
It is vital that trauma in brain injury work is also recognised as having the potential to impact on carers, families and treating professionals. The exposure to trauma can be mentally and emotionally draining, and can result in a significant risk of mental ill health which will then negatively impact their ability to appropriately care for the individual.
For this reason, it is important that carers are given adequate support and good quality supervision on a regular basis. Training and appropriate interventions should also be given to professionals who are involved in the field – it should never be overlooked that those there to support need support too.
The profession of solicitor is reportedly one of the most stressful roles in the UK today – I predict that personal injury work would top that by virtue of the clients we work with.
Burn-out does not discriminate and would urge all personal injury professionals to recognise when they themselves are displaying symptoms of trauma. It will be worth employing some self-care strategies – it’s the only way to continue to provide those human responses our clients need!
While it can be difficult to recognise trauma in some instances, and clients may be challenging, conversations are important. Speak to your client and the wider support system and family. These do not need to be in-depth, but could identify critical information that could be passed on to another professional, and enable the individual to access the specialist psychological support they need.
We can help
Some resources that might help professionals to support their client and to build on some of the ideas raised in this article:
- Blogs on racial trauma, intergenerational trauma and pain: Blog – PsychWorks Associates
- Factsheets on brain injury, trauma and self-care: Factsheets – PsychWorks Associates
- Podcast episodes on trauma, self-care, racism and brain injury: Podcast – PsychWorks Associates
Sometimes, specialist psychological and neuropsychological support is the most appropriate way to help. The PsychWorks Associates team offer consultancy, therapy and training on trauma, enabling professionals to deliver the best possible service to clients – while helping to recognise and mitigate the impact on themselves. Visit us to find out more at www.psychworks.org.uk
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